Psoriasis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of psoriasis.

Highlights

Overview:

Psoriasis is an inflammatory skin condition that affects about 2% of all Americans.
It is the most prevalent autoimmune condition.

There are several types of psoriasis. The most common type is plaque psoriasis, accounting
for about 90% of cases. Other types are guttate, inverse, erythrodermic, and pustular.

Causes

Doctors believe that psoriasis is caused by abnormalities in the immune system, enzymes,
and other factors that regulate skin cell division. In basic terms, an abnormal immune
response triggers inflammation and rapid production of immature skin cells.

Genes play a role in the development of psoriasis. Researchers have discovered that
a variation in a group of genes known as LCE can protect against the condition. One
of these genes codes for proteins that help maintain the skin's barrier.

Eight key psoriasis susceptibility genes (designated PSORS 1 to 8) seem to be involved
with psoriasis. Several different mutations of these genes are associated with psoriasis.

Risk Factors

35% of people with psoriasis have one or more family members with the disorder.

There may be a link between being overweight and psoriasis.

People with celiac disease have a higher risk of psoriasis. Gluten-free diets may
help people with celiac disease reduce psoriasis symptoms along with symptoms related
to celiac.

People with psoriasis may be at higher risk for dyslipidemia, or high cholesterol/triglyceride
levels.

Treatment

Treatment options for moderate to severe psoriasis include topical and systemic medications,
phototherapy, and excimer laser. Combination therapies are often more effective than
one treatment alone.

Phototherapy, which involves exposure of the skin to ultraviolet light, can help improve
the symptoms of psoriasis. Certain thin liquid moisturizers applied on the skin minutes
before phototherapy can help improve the beneficial effects of therapy. These include
Vaseline oil, mineral oil, and glycerol.

Biologic drugs that target the root of the disease, the immune system, are the newest
therapies considered in the treatment of psoriasis. Several drugs are approved and
more are under study.

Ustekinumab (Stelera) is a monoclonal antibody (biologic) injection approved in the
U.S. for the treatment of moderate to severe plaque psoriasis and psoriatic arthritis.
Its long term safety profile continues to be studied, but results so far are positive.

Apremilast (OTEZLA), a PDE4 inhibitor, is an oral anti-inflammatory. It was recently
approved by the FDA in 2014 for the treatment of moderate to severe plaque psoriasis.

Researchers continue to investigate the effects of other dietary factors, such as
omega-3 fatty acids (found in fish oil) and Vitamin D supplements, as well as lifestyle
factors in treating psoriasis.

Outlook

Psoriasis has been linked to an increased risk of:

Heart attack and cardiovascular disease

Crohn disease

Ulcerative colitis

Lymphoma

Depression

People with psoriasis should work with their doctors to prevent or manage these conditions.

Introduction

An estimated 7.5 million Americans (2.2% of the population) have psoriasis. Psoriasis
is a chronic skin disorder in which there are sharply defined red patches on the skin,
covered by a silvery, flaky surface. The disease activity may wax and wane over time.

The main disease activity leading to psoriasis occurs in the epidermis, the top five
layers of the skin. The process starts in the basal (deepest) layer of the epidermis,
where keratinocytes are made. Keratinocytes are immature skin cells that produce keratin,
a tough protein that helps form hair, nails, and skin. In normal cell growth, keratinocytes
grow and move from the bottom layer to the skin's surface and shed unnoticed. This
process takes about a month.

In people with psoriasis, the keratinocytes multiply very rapidly and travel from
the basal layer to the surface in about 4 days. The skin cannot shed these cells quickly
enough, so they build up, leading to thick, dry patches, or plaques. Silvery, flaky
areas of dead skin build up on the surface of the plaques that are shed. The skin
layer underneath (dermis), which contains the nerves and blood and lymphatic vessels,
becomes red and swollen.

The prevalence of psoriasis in men and women is about the same.

Types of Psoriasis

Various forms of psoriasis exist. Some can occur alone or at the same time as other
types, or one may follow another. The most common type is called plaque psoriasis,
also known as psoriasis vulgaris.

Plaque Psoriasis

Plaque psoriasis leads to skin patches that start off in small areas, about 1/8 of
an inch wide. They usually appear in the same areas on opposite sides of the body.

The patches slowly grow larger and develop thick, dry plaque. If the plaque is scratched
or scraped, bleeding spots the sizes of pinheads appear underneath. This is known
as the Auspitz sign.

Some patches may become ring-shaped (annular), with a clear center and scaly raised
borders that may appear wavy and snake-like.

As the disease progresses, eventually separate patches may join together to form larger
areas. In some cases, the patches can become very large and cover wide areas of the
back or chest. These are known as geographic plaques because the skin lesions resemble
maps.

Plaque psoriasis may persist for long periods of time. More often it flares up periodically,
triggered by certain factors such as cold weather, infection, or stress.

Patches most often occur on the:

Elbows

Knees

Lower back

They may also be seen on the:

Upper pelvic bone area

Bottom of the feet

Calves and thighs

Genital areas

Palms of the hands

Psoriasis of the scalp affects about 50% of people with psoriasis. In some cases,
the psoriasis may cover the scalp with thick plaques that extend down from the hairline
to the forehead.

Psoriasis patches rarely affect the face in adulthood. In children, psoriasis is most
likely to start in the scalp and spread to other parts of the body. Unlike in adults,
it also may occur on the face and ears.

Less Common Forms of Psoriasis

Psoriasis Form

Description of Skin Patches

Comments

Guttate Psoriasis

The patches are teardrop-shaped and appear suddenly, usually over the trunk and often
on the arms, legs, or scalp. They often disappear without treatment.

Guttate psoriasis can occur as the initial outbreak of psoriasis, often in children
and young adults 1 to 3 weeks after a viral or bacterial (usually streptococcal) respiratory
or throat infection. A family history of psoriasis and stressful life events are also
highly linked with the start of guttate psoriasis.

Guttate psoriasis can also develop in people who have already had other forms of psoriasis,
most often in people treated with widely-applied topical (rub-on) products containing
corticosteroids.

Inverse Psoriasis

Patches usually appear as smooth inflamed areas without a scaly surface. They occur
in the folds of the skin, such as under the armpits or breast, or in the groin.

Inverse psoriasis may be especially difficult to treat.

Seborrheic Psoriasis

Patches appear as red scaly areas on the scalp, behind the ears, above the shoulder
blades, in the armpits or groin, or in the center of the face.

Seborrheic psoriasis may be especially difficult to treat.

Nail Psoriasis

Tiny white pits are scattered in groups across the nail. Toenails and sometimes fingernails
may have yellowish spots. Long ridges may also develop across and down the nail.

The nail bed often separates from the skin of the finger and collections of dead skin
can build up underneath the nail.

Over half of the people with psoriasis have abnormal changes in their nails, which
may appear before other skin symptoms. In some cases, nail psoriasis is the only symptom. Nail psoriasis is linked to psoriatic arthritis.

This is a rare and severe form of psoriasis, in which the skin surface becomes scaly
and red. The disease covers all or nearly all of the body.

About 20% of such cases evolve from psoriasis itself. The condition may also be triggered
by certain psoriasis treatments and other medications, such as corticosteroids or
synthetic antimalarial drugs.

Pustular Psoriasis

Patches become pus-filled and blister-like. The blisters eventually turn brown and
form a scaly crust or peel off.

Pustules usually appear on the hands and feet. When they form on the palms and soles,
the condition is called palmar-plantar pustulosis.

Pustular psoriasis may erupt as the first occurrence of psoriasis, or it may evolve
from plaque psoriasis.

A number of conditions may trigger pustular psoriasis, including infection, pregnancy,
certain drugs, and metal allergies.

Pustular psoriasis can also accompany other forms of psoriasis and can be very severe.

Evidence to guide treatment is extremely limited.

Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory condition that leads to stiff, tender,
and inflamed joints. 10 to 20% of people with psoriasis develop psoriatic arthritis.
People with psoriasis who also have AIDS and people with severe psoriasis are at a
higher risk for developing PsA.

80% of people with PsA have psoriasis in the nails. Arthritic and skin flare-ups tend
to occur at the same time. It is not clear whether psoriatic arthritis is a unique
disease or a variation of psoriasis, although evidence suggests they are both caused
by the same immune system problem.

PsA is often divided into five forms. The forms differ according to the location and
severity of the affected joint:

Symmetric PsA: Symptoms occur in the same location on both sides of the body. The
condition usually affects multiple joints. In about half of the cases, symmetric PsA
will get worse. The condition is very similar to, but less disabling than, rheumatoid
arthritis. The psoriasis itself is often severe.

Asymmetric PsA: This form involves periodic joint pain and redness, usually in only
one to three joints, which can be the knee, hip, ankle, wrist, or one or more fingers.
The pain does not occur in the same location on both sides of the body.

Distal interphalangeal predominant (DIP): DIP involves the joints of the fingers and
toes closest to the nail. It occurs in about 5% of PsA cases.

PsA in the spine: Inflammation in the spinal column (spondylitis) is the primary symptom
in about 5% of PsA cases. Such people may have stiffness and burning sensations in
the neck, lower back, sacroiliac, or spinal vertebrae. The spine can be involved in
many people with PsA, even though stiffness and burning sensations in these areas
are not the primary symptoms. When it affects the spine, psoriatic arthritis most
frequently targets the sacrum (the lowest part of the spine). Movement is difficult.

Arthritis mutilans: This is a severe, deforming, and progressive form of arthritis.
It affects less than 5% of PsA cases. It mainly affects the small joints of the hands
and feet, but it can also be found in the neck and lower back. Arthritic and skin
flares and remissions tend to coincide.

People who start to smoke after developing psoriasis may delay the onset of psoriatic
arthritis. However, research has also linked smoking to an increased risk of psoriasis,
and because smoking causes serious health problems, it should not be considered as
a way to delay this type of psoriasis.

Causes

The precise causes of psoriasis are unknown. It is generally believed to be caused
by damage to factors in the immune system, enzymes, and other substances that control
skin cell division. This combination of factors prompts an abnormal immune response,
which causes inflammation and rapid production of immature skin cells.

Inflammatory Response and Autoimmunity

The Normal Immune System Response: The inflammatory process is a result of the body's immune response, which fights
infection and heals wounds and injuries:

When an injury or infection occurs, white blood cells are mobilized to rid the body
of any foreign invaders, such as bacteria or viruses.

The masses of blood cells that gather at the injured or infected site produce factors
to repair wounds, clot the blood, and fight infections.

In the process, the surrounding area becomes inflamed (red and swollen), and some
healthy tissue is injured.

The Infection Fighters: The primary infection-fighting units are two types of white blood cells, called
lymphocytes and leukocytes.

Lymphocytes are a type of white blood cell designed to recognize foreign substances
(antigens) and launch an offensive or defensive action against them. Lymphocytes include
two subtypes known as T cells and B cells:

B cells produce antibodies, which are designed to attack the antigens. Antibodies
can either ride along with a B cell or travel on their own.

T cells have special receptors attached to their surface that recognize the specific
antigen.

A type of T cell called a helper T cell stimulates B cells and other white blood cells
to attack a foreign substance. In psoriasis, however, the helper T cell appears to
direct the B cells to produce autoantibodies ("self" antibodies), which attack the
body's own skin cells. In psoriatic arthritis, cells in the joints also come under
attack.

Helper T cells also release or stimulate the production of powerful immune factors
called cytokines. In small amounts, cytokines are very important for healing. However,
the high level of these cytokines that occurs in psoriasis can cause serious damage,
including inflammation and injury during the psoriasis disease process.

Genetic Factors

A combination of genes is involved with increasing a person's susceptibility to the
conditions leading to psoriasis. However, researchers are still unsure as to exactly
how the disease is inherited.

HLA Molecules: The processes leading to all autoimmune diseases involve the human leukocyte antigens
(HLA), a group of protein markers found on cells. Most immune disorders are associated
with problems in how the body reacts to these different protein markers or antigens.
However, other genetic and environmental factors are required to actually trigger
the disease.

Eight key psoriasis susceptibility genes (designated PSORS 1 to 8) seem to be involved
with psoriasis. Certain variations or changes in these genes may increase the risk
of psoriasis. These same variations linked to psoriasis and psoriatic arthritis is
also associated with four known autoimmune diseases:

Type 1 diabetes

Grave's disease

Celiac disease

Rheumatoid arthritis

This suggests that all of these diseases have the same genetic basis.

The presence of a recently identified variation in a group of genes known as LCE can
protect against the development of psoriasis.

Triggers

Weather, stress, injury, infection, and medications, while not direct causes, are
often important in triggering, and worsening, the psoriasis.

Weather: Cold, dry weather is a common trigger of psoriasis flare-ups. Hot, damp, sunny weather
helps relieve the problem in most people. However, some people have photosensitive
psoriasis, which actually improves in winter and worsens in summer when skin is exposed
to sunlight.

Stress and Strong Emotions: Stress, unexpressed anger, and emotional disorders, including depression and anxiety,
are strongly associated with psoriasis flare-ups. Research has suggested that stress
can trigger specific immune factors associated with psoriasis flares.

Infection: Infections caused by viruses or bacteria can trigger some cases of psoriasis. For
example:

Streptococcal infections in the upper respiratory tract, such as tonsillitis, sinusitis,
and strep throat, are known to trigger guttate psoriasis in children and young adults.
These infections may also worsen ordinary plaque psoriasis.

Human immunodeficiency virus (HIV) is also associated with psoriasis.

An uncommon strain of human papillomaviruses (HPV), called EV-HPV, has been associated
with psoriasis. Although EV-HPV is probably not a direct cause, it may play a role
in the continuation of psoriasis. This HPV strain is not one of the viruses that cause
cervical cancer and genital warts.

Skin Injuries and the Koebner Response: The Koebner response is a delayed response to skin injuries, in which psoriasis
develops later at the site of the injury. In some cases, even mild abrasions can cause
an eruption, which may be why psoriasis tends to frequently occur on the elbows or
knees. However, psoriasis can develop in areas that have not been injured.

Medications: Drugs that can trigger the disease or cause a flare-up of symptoms include:

Beta blockers, drugs used to treat high blood pressure and heart problems

Chloroquine, a medicine used to treat malaria

Lithium for bipolar disorder treatment

Indomethacin, a nonsteroidal anti-inflammatory drug (NSAID). Note: Other NSAIDs, such
as meclofenamate, may actually improve the condition.

Progesterone, used in female hormone therapies

Severe flare-ups may occur in people with psoriasis who stop taking their steroid
pills, or who discontinue the use of very strong steroid ointments that cover wide
skin areas. The flare-ups may be of various psoriatic forms, including guttate, pustular,
and erythrodermic psoriasis. Because these drugs are also used to treat psoriasis,
this rebound effect is of particular concern.

Medications that cause rashes (a side effect of many drugs) can trigger psoriasis
as part of the Koebner response.

Risk Factors

Risk factors for psoriasis include:

Age under 20: 40% of people develop the condition before age 20. Psoriasis (most often plaque
psoriasis) can even occur in infants.

Climate: Some studies have found that the disorder develops earlier and more frequently in
colder climates. For example, psoriasis occurs more often in African-Americans and
in Caucasians who live in colder climates than in people of any ethnicity who live
in Africa.

Ethnicity: Psoriasis is uncommon in Native Americans of either North or South American descent.

Family history of the disease: 35% of those with psoriasis have one or more family members with the disorder.

Lifestyle factors: Smoking, obesity, and alcohol use and abuse increase the risk of getting psoriasis
and boost its severity.

Co-morbidities: Having other conditions, such as celiac disease, increases the risk of psoriasis.

Diagnosis

A microscopic examination of tissue taken from the affected skin patch is needed to
make a definitive diagnosis of psoriasis and to distinguish it from other skin disorders.
Usually in psoriasis, the examination will show a large number of dry skin cells,
but without many signs of inflammation or infection. Specific changes in the nails
are often strong signs of psoriasis.

Disease Severity

The severity of psoriasis ranges from one or two flaky inflamed patches to widespread
pustular psoriasis that, in rare cases, can be life threatening. To help determine
the best treatment for a patient, doctors usually classify the disease as mild to
severe. The classification depends on how much of the skin is affected:

Mild psoriasis affects less than 3% of the body surface. Most cases of psoriasis are
limited to less than 2% of the skin.

Moderate psoriasis covers 3 to 10% of the skin.

If more than 10% of the body is affected, the disease is considered severe.

The palm of the hand equals 1% of the body.

The severity of the disease is also measured by its effect on a person's quality of
life.

The National Psoriasis Foundation has proposed a new classification method. The group
suggests a two-tiered system that classifies people with psoriasis as needing either
local or body-wide (systemic) treatment. Physicians may also use several assessment
tools to evaluate severity.

In general, severe or widespread psoriasis is harder to treat. However, some forms
of psoriasis can be very resistant to treatment, even though they are not categorized
as severe. They include:

Any psoriasis on the palms and soles (hand and foot psoriasis)

Inverse psoriasis (which occurs in the folds of the skin)

Scalp psoriasis

Psoriatic arthritis

Risk factors, triggers, and comorbidities will also be assessed at the time of diagnosis.

Treatment

Many creams, ointments, lotions, and pills are available to treat psoriasis. Some
people require only over-the-counter treatment, or even no treatment.

Many people with psoriasis, however, do not respond to over-the-counter remedies and
lifestyle changes, and require aggressive treatments. In some cases, such treatments
need to be lifelong.

In general, there are three treatment options for people with psoriasis:

Topical medications, such as lotions, ointments, creams, and shampoos

Body-wide (systemic) medications, which are pills or injections that affect the whole
body, not just the skin

Phototherapy, which uses light to treat psoriasis lesions

Individual needs vary widely, and treatment selection must be carefully discussed
with the doctor.

Treatment Sequences

Giving treatment in a stepwise order can help provide quick symptom relief and long-term
maintenance. It involves three main steps:

The quick fix, to clear the psoriatic lesions during an acute outbreak (a high-strength
topical steroid in mild-to-moderate psoriasis or an oral immunosuppressant in more
severe cases)

The transitional phase, intended to gradually introduce the maintenance drug

Ongoing maintenance therapy

Choices for transitional or maintenance treatments depend on the severity of the condition.

In severe chronic cases, the doctor may recommend rotational therapy. This approach
alternates treatments. The goal is to prevent severe side effects or the build-up
of resistance from long-term use of a single medicine. An example of a rotational
schedule may be the following:

The person gets phototherapy for about 2 years.

The person then takes one or two powerful body-wide drugs for 1 to 2 years and stops.

Phototherapy starts again, and the cycle repeats.

Doctors increasingly use combinations of pills, creams, ointments, and phototherapy
instead of single medications. Combinations of oral treatments are particularly useful
because the doses of each drug can be reduced. This lowers the risk of severe side
effects. Thousands of combinations are possible, and people should discuss with their
doctors the best treatment for their individual needs.

Topical Medications

Topical medications are those applied only to the surface of the body. They come in
the following forms:

Creams

Foams

Gels

Lotions

Occlusive tapes

Ointments

Shampoos

Solutions

Sprays

In general, topical treatments are the first line for mild-to-moderate psoriasis,
but they may also be used, alone or in combination, with more powerful treatments
for moderate-to-severe cases. Topical medicines rarely clear up symptoms completely,
however.

Topical Corticosteroids

Topical corticosteroids are the mainstay of psoriasis treatment in the United States.
These drugs work for most people because they:

Decrease inflammation

Block cell production

Relieve itching

Corticosteroids are available in a wide range of strengths, and are generally given
as follows:

Less potent drugs are used for mild-to-moderate psoriasis.

Stronger drugs are reserved for more severe disease.

Topical steroids are often rated by how strong or potent they are:

Low potency (some are available over-the-counter)

Low-to-medium potency

Medium- to upper-mid potency

High potency

Very high potency

In the past, topical steroids were used twice a day. For some people, certain drugs
may work just as well if applied once a day. Both high-potency steroids, and possibly
medium-strength steroids, such as triamcinolone (Aureocort, Tri-Adcortyl), may be
beneficial as a once-daily treatment.

However, corticosteroids used alone are not enough for most people. Combining topical
steroids with other topical drugs (see below) is often needed. Many people also need
oral medicines.

Side Effects: The more powerful the corticosteroid, the more effective it is. But more powerful
steroid medications also have a higher risk for severe side effects, which may include:

Acne

Burning

Dilated (widened) blood vessels

Skin dryness

Skin irritation

Loss of skin color

Thinning of the skin; skin may become shiny, fragile, and easily broken

Loss of Effectiveness. In most cases, people become tolerant to the effects of the drugs, and the drugs
no longer work as well as they should. Some experts recommend using intermittent therapy
(also called weekend or pulse therapy). This type of treatment involves applying a
high-potency topical medication for 3 full days each week.

Topical Vitamin D3-Related Treatments

A topical form of vitamin D3, calcipotriene (Dovonex) is proving to be both safe and
effective. It is now available in a foam preparation, which makes using it even easier.
Several other topical vitamin D3-related drugs that are showing promise include maxacalcitol,
tacalcitol, and calcitriol (Vectical).

Calcipotriene appears to:

Block skin cell reproduction

Enhance the maturity of keratinocytes (the impaired skin cells in psoriasis)

Act as an anti-inflammatory

It works just as well as moderate topical corticosteroids, short-term anthralin, and
coal tar in improving mild-to-moderate plaque psoriasis. But unlike with steroids,
people do not develop thinning of the skin or tolerance to the drug.

Using the drug in combination with other topical and body-wide treatments may improve
its effectiveness. Calcipotriene does not work as well as the highest potency corticosteroids,
but combining both medications is proving to be more effective than taking either
one alone. Taclonex, an ointment containing both calcipotriol and betamethasone, is available for the
treatment of adults with psoriasis. Studies show the combination works better than
either drug alone.

Combining vitamin D ointments with systemic medicines, notably methotrexate, acitretin,
or cyclosporine, increases its effectiveness. Because combining medications allows
people to use lower doses of both medications, combination treatments reduce side
effects.

Studies also report success in some people who use vitamin D ointments in combination
with phototherapy treatment.

Side Effects: Calcipotriene may cause the following side effects:

A possible lowering of vitamin D levels, which may affect bone growth in some children

A possible increase in blood calcium levels (seen in some people who apply calcipotriene
to large areas)

Skin irritation in 20% of people, particularly on the face and in skin folds

Calcipotriene appears to cause greater skin irritation than potent corticosteroids.
Diluting the drug with petrolatum or applying topical corticosteroids to sensitive
areas may prevent this problem.

Coal Tar

Coal tar preparations have been used to treat psoriasis for about 100 years, although
their use has declined with the introduction of topical vitamin D3-related medicines.
Crude coal tar stops the action of enzymes that contribute to psoriasis, and helps
prevent new cell production. Tar is often used in combination with other drugs and
with ultraviolet B (UVB) phototherapy.

Coal tar preparations have the following drawbacks:

They stain clothing

They cause skin irritation

People using coal tar have increased sun sensitivity and increased risk of sunburn
for up to 24 hours after use

Anthralin

Anthralin (Dritho-Scalp, Drithocreme, and Micanol) slows skin cell reproduction and
can produce remissions that last for months. It is recommended only for chronic or
inactive psoriasis, not for acute or inflamed eruptions. People with kidney problems
should use anthralin with caution.

As with tar, anthralin's use has also declined since the introduction of the topical
vitamin D-related medicines, but newer formulations, such as Micanol, have made its
use more tolerable. Micanol (Psoriatec) is an anthralin formulated in microcapsules,
which dissolve and allow the drug to be delivered directly to the target skin areas.
It is particularly useful for scalp psoriasis, and it is less likely than other formulations
to stain.

Side Effects and Drawbacks: Anthralin may cause the following problems:

Skin irritation and burning

Staining of clothes, hair, fabrics, plastics, and other household products

People should not use anthralin on the face. Fair-skinned people should generally
avoid it.

Triethanolamine (CuraStain) is a chemical that can neutralize anthralin and help reduce
irritation from short-contact anthralin treatment. It should be applied 1 or 2 minutes
before washing off the anthralin. It is then reapplied after drying the skin.

Washing stained items with hypochlorite (Clorox) detergents can help remove stains.
Many people use disposable gloves while applying the treatment to avoid staining their
hands.

Application: Apply anthralin only to the psoriasis plaques. Rub in the cream well and wipe off
any excess. Wash off only with lukewarm water, not soap. Using hot water will trigger
the staining action. A technique called short-contact anthralin therapy (SCAT), also
called minute therapy, is useful for local areas of psoriasis. In such cases, anthralin
is applied for only 10 minutes to an hour.

Topical Retinoids

Retinoids are related to vitamin A. They are used for various skin disorders. Tazarotene
(Tazorac) was the first topical retinoid found to be effective for mild-to-moderate
psoriasis. It is available in cream or gel form.

Unlike steroids, retinoids do not cause thinning of the skin or tolerance to the drug.
Only a very small amount is needed on each lesion. Retinoid gel can be used on the
scalp and nails, but it is not recommended for the genital areas or around the eyes.
The gel should be used on only 20% of the body at any time; the cream can be used
on up to 35% of the body.

Combining topical retinoids with other psoriasis treatments, such as topical steroids,
works better than using the drug by itself.

Side Effects: Tazarotene may cause dryness and irritation of healthy skin. Applying zinc oxide
and moisturizer around the treated area can protect healthy skin.

At levels high enough to be effective for treating psoriasis, tazarotene can cause
severe skin irritation on treated areas. This medicine is usually used in combination
with other treatments, allowing people to use a lower dose. Mixing the drug in equal
amounts with petroleum jelly (Vaseline) and then gradually increasing the amount of
tazarotene may help the skin areas become less sensitive. The skin can become very
red while it is actually improving.

Vitamin A derivatives (drugs related to vitamin A) have been associated with birth
defects and should not be used by women who:

Are pregnant

Wish to conceive

Are nursing

Salicylic Acid

Salicylic acid applied to the skin helps remove scaly plaque and enhance the actions
of other medications. It should not be used to cover wide areas of the body, because
it can cause nausea and ringing in the ears. Combinations with high-potency steroids,
such as mometasone furoate, clobetasol propionate, and betamethasone, are proving
to be very helpful.

Occlusive Tapes

Watertight (occlusive) tapes or wrappings may help heal psoriasis. Occlusive tapes
are particularly useful for psoriatic cuts on the palms and soles. In such cases,
the tape should be applied across the cuts until they heal.

Occlusive tapes retain sweat, which helps restore moisture to the outer skin layer
and prevent scaling. They also protect against abrasions and irritation.

High-Potency Corticosteroid Tapes: Applying a corticosteroid beneath an occlusive tape, or using a tape that already
has a potent corticosteroid (Cordran Tape) such as flurandrenolide may be especially
beneficial. Studies are showing that high-potency corticosteroid-containing tapes
are more effective than high-potency corticosteroid ointments alone.

However, the tapes are expensive and are associated with:

A high rate of skin irritation

Increased infections

A greater chance of symptoms returning after treatment is stopped

Infection risk may be reduced by changing tapes every 12 hours.

The use of corticosteroids under occlusive tapes on large areas of psoriasis also
increases the risk for adrenal insufficiency, a sometimes dangerous condition that
occurs because the body loses its ability to produce natural steroids. Children are
especially vulnerable to this effect.

Other Medications with Occlusive Tapes or Wrappings: The tapes may be used in combination with other medications, such as fluorouracil.
Occlusive wrappings are not usually used with tazarotene (Tazorac), and should never
be used without a doctor's recommendation.

Topical Immunosuppressants

Tacrolimus (Protopic) and Pimecrolimus (Elidel) are approved for the treatment of
psoriasis. These topical agents block the immune response which leads to skin inflammation
and plaque build-up. They are especially useful for sensitive areas, such as the face,
and are considered first-line treatment for flexural psoriasis. They are approved
for use in children ages 2 and older. Adverse effects are rare, but there is a label
warning of the increased risk for skin malignancy and lymphoma with long term use.

Systemic Medications

Systemic treatment uses various medications that affect the whole body, not just the
skin. Many systemic drugs used for psoriasis are also used for other severe diseases,
including autoimmune diseases (especially rheumatoid arthritis) and cancer.

Systemic treatments for psoriasis may be taken by mouth or injection. The medicines
can have significant side effects and are generally reserved for severe psoriasis.

Systemic medications approved for treating psoriasis include:

Cyclosporine

Methotrexate

Retinoids

Biologic Response Modifiers

Psoralen

Apremilast

Off-label Systemics: Physicians sometimes prescribe medications off-label. The medications below are
not specifically approved for psoriasis, but they are sometimes effective. The following
drugs are FDA approved for other conditions, such as acne or cancer, but may sometimes
be prescribed for psoriasis:

Hydrea (hydroxyurea)

Isotretinoin

Mycophenolatemofetil

Sulfasalazine

6-thioguanine

As with all medications for psoriasis, people should use the lowest strength medication
first. The primary treatment is called a first-line treatment, the next is known as
a second-line treatment, and so on. Combinations of medications are often used.

Several new agents to treat psoriasis are under study, including oral medications
and monoclonal antibodies. The following agents show promising results for plaque
psoriasis but none have yet been approved for use:

IxekizumabI (anti-interleukin-17 monoclonal antibody)

Brodalumab (anti-interleukin-17-monoclonal antibody)

Secukinumab (anti-interleukin-17A monoclonal antibody)

Certolizumabpegol, or CZP (antitumor necrosis factor [TNF] agent)

Methotrexate

Methotrexate (Rheumatrex) is a biologic drug that interferes with cell reproduction
and has anti-inflammatory properties. It is a first-line, or primary, systemic drug
used to treat adults with severe psoriasis.

The drug is taken weekly, not daily.

Side Effects: Many people are able to tolerate methotrexate with few side effects. Possible side
effects include:

Anemia, usually causing no noticeable symptoms

Headache

Mild and slow hair loss that is reversible when the medication is stopped

Increased likelihood of becoming sunburned

Mouth sores

Nausea, usually mild and improves over time

Possible muscle aches

Rash

Vomiting (rare)

Many of these side effects are due to folic acid deficiency. People should ask their
doctor if they should take folic acid supplements (generally recommended at 1 mg daily).

More serious, but relatively uncommon side effects include:

Increased risk for infections, particularly shingles and pneumonia. Methotrexate suppresses
the immune system. People with active infections should avoid this drug.

Infertility, miscarriage, and birth defects. This drug should not be used during pregnancy,
because it can cause miscarriages or birth defects. It may harm fertility in men.

Kidney damage.

Liver damage, most commonly in people with existing liver problems. Regular monitoring
for liver toxicity includes blood tests and sometimes liver biopsies. People who are
properly monitored rarely have any permanent liver damage.

Cough and shortness of breath. Risk factors for these side effects include diabetes,
existing lung problems, protein in the urine, and the use of rheumatoid arthritis
drugs of a type called DMARD.

Despite methotrexate's side effects, some experts view it as the best therapy for
widespread plaque psoriasis. It may also be effective for some people with generalized
erythrodermic and pustular psoriasis.

Methotrexate appears to be effective in children, but more safety research is needed.

Drug Interactions: Many drugs interact with methotrexate, occasionally with harmful results. For example,
the antibiotic trimethoprim-sulfamethoxazole increases the toxicity of methotrexate.

Taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen,
or naproxen at the same time as methotrexate may change the blood levels of methotrexate.
Always talk with your doctor before taking these or any other medications in combinations.

People Who Should Avoid Methotrexate: Pregnant and nursing mothers should never take methotrexate because it increases
the risk for severe, even fatal, birth defects and miscarriage. The drug should be
discontinued several months before the actual pregnancy. Methotrexate may also cause
temporary impairment of fertility in men. People with Hepatitis B should not take
methotrexate.

People with the following conditions are unlikely to be given methotrexate:

Alcoholism

Anemia or other blood abnormalities

Kidney problems

Liver problems (including hepatitis)

Peptic ulcers

Suppressed immune system

Oral Retinoids

Oral retinoids are vitamin A-related medications taken by mouth. This group of medicines
is also a first-line treatment for adults with severe psoriasis. Oral retinoids used
for psoriasis include acitretin (Soriatane) and isotretinoin (Accutane).

Acitretin is the retinoid of choice and may be dramatically effective for severe psoriasis,
particularly pustular or erythrodermic types. It is also effective in a low-dose formulation
for symptoms of nail psoriasis. When used alone, it is much less effective against
more common forms of psoriasis, such as plaque or guttate psoriasis. However, when
combined with UVB phototherapy it can markedly improve the response, even in people
with these forms of psoriasis.

Accutane, more commonly used to treat acne, is far less potent than acitretin, but
it may still be effective against pustular psoriasis. The drug may also be effective
with phototherapy.

Oral retinoids help control cell reproduction and have anti-inflammatory properties.
They may even improve arthritis that accompanies psoriasis.

Combination therapy: Acitretin may work best when combined with other treatments, usually topical drugs
and especially phototherapy. Combination therapy allows lower doses of oral retinoids
to be used, which diminishes many skin and mucus membrane side effects. Acitretin
combined with phototherapy has some of the greatest success rates of any treatment.

Side Effects: All retinoids have the same potentially serious toxicities, as do high doses of
vitamin A. Side effects include:

In rare cases, retinoids, particularly isotretinoin, may cause a condition called
benign intracranial hypertension (pseudotumor cerebri), which occurs in the brain.
Symptoms include headache, nausea, vomiting, and blurred vision. People experiencing
these symptoms should call a doctor immediately and stop taking the drug.

Oral retinoids should not be taken during pregnancy.

Despite these side effects, oral retinoids remain among the safest whole-body therapies
for psoriasis. A low-fat diet, aerobic exercise, and fish oil supplements may help
reduce the side effects. Certain cholesterol-lowering drugs, including gemfibrozil
(Lopid) and atorvastatin (Lipitor), may help control triglyceride levels.

Maintenance doses should be as low as possible and should be taken every second or
third day.

Oral Retinoids and Pregnancy

Taking retinoids during pregnancy significantly increases the risk for severe birth
defects in the unborn child. Pregnant or nursing women, or those planning to become
pregnant, should not use these drugs. Women of childbearing age who take retinoids
should have regular pregnancy tests.

Acitretin is an oral retinoid used typically for first line-therapy of chronic palmoplantar
or pustular psoriasis. It may be used in combination with other therapies to treat
plaque psoriasis. Acitretin should not be given to any woman who may become pregnant
within 3 years of taking it. Drinking alcohol changes acitretin to a retinoid that
is stored in fat cells for 3 years. It may have the potential to cause birth defects
during that time. Be cautious about cooking products and over-the-counter preparations,
such as cough syrup, which may contain alcohol.

Women who are pregnant or who plan to become pregnant should not use isotretinoin.
Everyone who takes, prescribes, or dispenses the drug must enroll in a national registry
called iPLEDGE, which helps to ensure that no woman starts retinoid therapy while
pregnant or trying to get pregnant.

Cyclosporine

Cyclosporine (Neoral, Sandimmune, and SangCya) blocks certain immune factors and may
be effective for all forms of psoriasis. It is also a first-line, or primary, systemic
drug used to treat adults with severe psoriasis, von Zumbusch pustular psoriasis,
or erythrodermic psoriasis. Neoral is the preparation used most often for psoriasis,
and it clears psoriasis in many patients within 8 to 12 weeks.

Side Effects: Cyclosporine has significant side effects if used for a long time, notably kidney
problems and non-melanoma skin cancers. It should be reserved for people who do not
respond to phototherapy or less potent systemic medications (such as, methotrexate
or acitretin).

Skin cancers (People who take cyclosporine after PUVA therapy has a higher incidence
of squamous cell skin cancer. The risks are greatest with long-term and previous use
of PUVA, methotrexate, or other immunosuppressants.)

To reduce complications of cyclosporine, the dosage is decreased after improvement
occurs. Maintenance therapy is usually limited to a year, although some experts believe
that a microemulsion form of Neoral (Neoral-Neo) may be safe to use for up to 2 years.
People should be monitored regularly for high blood pressure and signs of kidney or
liver problems and skin cancers.

People Who Should not Use Cyclosporine: Because the drug suppresses the immune system, people with active infections or
cancer should avoid it. People with uncontrolled high blood pressure and impaired
kidney function should also not use this medication. Cyclosporine therapy for children
with psoriasis has not been well studied.

Newer forms of cyclosporine that have fewer side effects are being investigated.

Biological Response Modifiers

Biological response modifiers, sometimes called "biologics," belong to a new class
of drugs that are considered the most exciting development in psoriasis treatment.
Biologics are genetically engineered drugs that interfere with specific components
of the autoimmune response. Because of their precise targets, these drugs do not damage
the entire immune system like general immunosuppressants. Biologic drugs are expensive.

Biologics are traditionally second- or third-line treatments, and may be used alone
or in combination with first-line systemic drugs. Depending on the severity of psoriasis,
some of these drugs may be used earlier in the course of treatment. Studies of these
medications have primarily been done on people who are over 18 years old.

The biologics traditionally used to treat plaque psoriasis (described below) are now
also considered in the treatment of pustular psoriasis. Many studies testing new biologics
are underway.

There are different types of biologics used to treat psoriasis:

Tumor necrosis factor (TNF) blockers target the chemical messenger TNF-alpha, which
is released during the inflammatory response.

Etanercept (Enbrel) is approved for the treatment of moderate-to-severe plaque psoriasis,
and for people with psoriatic arthritis. The drug is given either alone or in combination
with methotrexate. Side effects include infections and lymphoma. People inject themselves
under the skin once or twice a week for 12 weeks. Continuing etanercept after 12 weeks
may lower the severity of disease without increasing infections or side effects. The
drug may be effective in people with psoriasis who have not responded to other biologic
drugs or other therapies, and it is also effective in people who have not yet received
biologic treatments. Although etanercept has not been studied in children who have
psoriasis, it has been shown to be safe and effective for treating children with rheumatoid
arthritis.

Adalimumab (Humira) has been approved for moderate-to-severe chronic plaque psoriasis.
It is given by injection weekly at first, and then bi-weekly. It appears better tolerated
than methotrexate. This drug is also approved for psoriatic arthritis.

Infliximab (Remicade) is a TNF inhibitor given by injection. It is often considered
for, second- or third-line therapy for chronic plaque psoriasis.

Golimumab (Simponi) is approved for the treatment of active psoriatic arthritis. It
is patient-administered by injection and taken once per month. It is sometimes combined
with methotrexate. Side effects include increased risk of infection, cancers and lymphoma,
cardiac conditions, liver or nervous system disorders.

Side effects and risks of TNF blockers:

All of the TNF inhibitors carry the potential for an increased risk of serious infections.
Upper respiratory infections are the most common infections that occur.

Uncommon infections caused by fungi and tuberculosis bacteria also occur in people
using anti-TNF medications. In 2009, the FDA issued a warning to healthcare professionals,
stressing the need to test for these infections in people using anti-TNF medications
who display symptoms of body-wide (systemic) illness. Because these infections are
uncommon, previous delays in diagnosis have resulted in death in some people.

People receiving these drugs are at risk of reactivating old tuberculosis (TB) infections.
People are also at a higher risk for developing TB. The FDA recommends TB screening
with a purified protein derivation (PPD) skin test.

Whether TNF inhibitors increase the risk for lymphoma and skin cancers is a debated
issue.

A number of other side effects are also possible.

Monoclonal Antibodies

Human monoclonal antibodies bind to proteins or cells and stimulate the immune system
to destroy those cells.

Ustekinumab (Stelera) was approved by the FDA in 2009 for the treatment of moderate-to-severe
plaque psoriasis. It is given by injection about every 3 months and may be used as
first-line treatment. People should discontinue use prior to any elective surgery,
or after 4 months of treatment without adequate response. In 2013, it was FDA approved
to treat psoriatic arthritis.

Apremilast

Apremilast (OTEZLA), a PDE4 inhibitor, is an oral anti-inflammatory. It was approved
by the FDA in 2014 for the treatment of moderate to severe plaque psoriasis. People
may see an improvement in about 4 months. Side effects may include:

Diarrhea

Nausea

Upper respiratory tract infection

Headache.

It has not yet been studied for safety in pregnant women.

Other Second- and Third-Line Treatments

Immunosuppressants: Some oral immunosuppressants being studied for psoriasis include tacrolimus (Prograf),
pimecrolium, and sirolimus. Studies have been limited, however. Side effects of these
medications are similar to those of cyclosporine. Pimecrolimus may specifically target
the skin and have fewer side effects. (Some immunosuppressants are also being studied
as topical treatments.)

Phototherapy

Phototherapy means to treat with light.

When sunlight penetrates the top layers of the skin, the ultraviolet radiation bombards
the DNA inside skin cells and injures it. This can cause wrinkles, aging skin, and
skin cancers. However, these same damaging effects can destroy the skin cells that
form psoriasis patches.

Phototherapy for psoriasis can be given as ultraviolet A (UVA) light in combination
with medications, or as variations of ultraviolet B (UVB) light with or without medications.
Not everyone is a candidate. For example, phototherapy may not be appropriate for
people who should avoid sunlight or those with very severe psoriasis.

Certain ointments on the skin can have a negative effect and block the beneficial
rays from penetrating the skin. However, some moisturizers with low reflective and
absorption qualities applied within 5 minutes of light therapy can enhance phototherapy
benefits. These may include:

Calcipotriene

Mineral oil

Glycerol

Vaseline oil

Oleic acid

It is unclear which of the phototherapy options below is best. More research is needed.

Psoralen and Ultraviolet A Radiation (PUVA)

Ultraviolet A (UVA) is the main part of sunlight. PUVA therapy uses a photosensitizing
medication (usually psoralen) in combination with UVA radiation. A photosensitizing
medication makes a person more sensitive to light. Treatment with psoralen and UVA
is referred to as PUVA. This approach is very powerful and effective in more than
85% of people who use it. However, it poses a higher risk for skin cancers than treatment
with UVB.

PUVA treatments cause inflammation and redness in the skin within 2 to 3 days after
treatment. Such damage inhibits skin cell proliferation and reduces psoriasis plaque
formation.

Forms of psoralen include methoxsalen, 8-methoxypsoralen (8-MOP), or bergapten (5-MOP).
The effectiveness of the treatment is based on a chemical reaction in the skin between
the psoralen and light, which creates the redness and inflammation that prevents the
psoriasis disease process.

People should avoid this treatment if they are taking drugs or have conditions that
cause them to be light sensitive. They should also take protective measures before,
during, and after each treatment.

Psoralen is typically taken by mouth in the form of 8-methoxypsoralen (for example,
Oxsoralen) 75 minutes to 2 hours before the treatment starts. Psoralen reaches the
skin through the bloodstream, where it increases the skin's sensitivity to UVA radiation.
Topical preparations of psoralen are alternatives to pills. They can be "painted on"
or applied to the affected areas by soaking or bathing in a psoralen solution. PUVA-bath
therapy may be especially useful for persistent psoriasis on the palms and soles,
or for people with liver disease or who get severe nausea from taking the pill form.
UVA should be given within 15 minutes of using topical psoralen.

The person enters and stands in a light box, which is a unit lined with ultraviolet
lamps. The initial UVA exposure time is very short (seconds to several minutes), and
then increases to 20 minutes or longer. The amount of time a person is exposed to
UVA rays depends on the skin type, with the shortest times recommended for fair-skinned
people.

Treatments may be repeated two or three times a week. They should never be performed
more frequently than once every other day, because the full effects of the treatments
are not evident for 48 hours. It takes an average of about 25 PUVA treatments for
the full effect to be seen, but during that period treatment intensity may vary.

If there is no response after 10 treatments, the doctor may increase the UVA energy.

If there is still no response after 15 treatments, the psoralen dosage may be increased.

If a person's skin does not improve at all or worsens, the treatment is temporarily
stopped. PUVA may be causing a toxic response in such cases, and often, the condition
gradually improves over the following 2 weeks.

If the skin does not improve over the following 2 weeks, PUVA treatment has failed.
If skin improves during this resting period, treatment resumes.

Maintenance Phase: Once the psoriasis has improved by about 95%, the person may be put on a maintenance
schedule. Often only one or two treatments a month are needed, but some people may
need more frequent treatments. As maintenance continues and the interval between treatments
lengthens, people may become more susceptible to tanning and sunburn. They should
reduce exposure to natural sunlight during this time.

Combinations: Combining acitretin, calcipotriene, methotrexate, or tazarotene gel with PUVA may
enhance its effectiveness or increase the response. In addition, combinations may
allow for lower doses of radiation or medications to be used, minimizing side effects.
Retinoids may also help protect against skin cancers (methotrexate may increase the
risk). In some cases, people who are resistant to PUVA or UVB may respond when the
phototherapies are combined.

Side Effects and Complications of PUVA.

The psoralen methoxsalen causes a general ill feeling and nausea in 20% of people.
Dividing up the dose and taking it in 15-minute intervals with food, or taking ginger
20 minutes before taking the drug may be helpful.

Skin reactions, including itching, sunburn, and blistering, are common. These can
generally be avoided with careful administration of PUVA therapy and protective measures.
Antihistamines, baths with special oatmeal preparations (Aveeno), and capsaicin ointment
(Zostrix) may help.

After treatment, white spots commonly develop in the areas where psoriasis plaques
were, particularly in people with naturally darker skin. If these spots are troublesome,
tanning products may help darken them. Small, dark raised spots called PUVA lentigines
may also develop in affected areas with long-term treatment.

The prolonged standing that may be required in the light box may trigger fainting
in people with certain heart or blood pressure problems.

People with liver disease should discuss using topical psoralens because oral forms
may have adverse effects on the liver.

UVA penetrates the skin more deeply than UVB, so there is a greater danger of deep
skin damage, accelerated skin aging, and skin cancers. Anyone who needs to avoid sunlight
should not get this treatment.

The procedure increases the risk for cataracts if the eyes are not protected for up
to 24 hours after treatment.

Special Warning on PUVA and Skin Cancers: It has been known for some time that PUVA can change DNA and cause genetic mutations.
PUVA is known to increase the risk for squamous cell skin cancer and slightly increase
the risk for basal cell skin cancer, both of which are nearly always curable. One
study also reported an increased risk of melanoma. The risk for skin cancers is higher
in people who have:

A family or personal history of skin cancer

Light skin and fair or red hair

Received radiation or x-ray treatments or taken immune suppressing drugs

Received more than 200 PUVA treatments

Discussions are under way about discontinuing PUVA treatment of psoriasis. The following
are pro and con arguments about the procedure:

Opponents of PUVA argue that studies suggest a long-term risk for melanoma, starting
about 15 years after treatment, particularly in people who receive more than 250 treatments.

Supporters of PUVA argue that it is not yet known whether the people who developed
melanoma experienced sunburn during the procedures, or if they already had risk factors
for skin cancers. If so, properly given treatments could still be considered safe
for people without risk factors. They also argue that PUVA is still the most effective
treatment for severe psoriasis, and the alternatives are usually very powerful and
relatively new drugs that may have even more serious side effects. Furthermore, adding
retinoids may protect against skin cancers while increasing the treatment's effectiveness.

Protective Measures with PUVA Therapy

Side effects of UVA radiation can be severe. Protective measures are needed during,
before, and after treatment. People should avoid prolonged exposure to the sun for
24 hours before the oral treatment starts.

Protective Measures During Treatment:

People should wear specially designed goggles to protect the eyes from UVA radiation.

Sensitive areas, such as the genitals, abdominal skin, and breasts should be covered
until the exposed areas tan, which usually occurs after about a third of the treatment
period. Because PUVA is associated with a high risk for genital skin cancers, male
genitals must be covered throughout the process.

The following safety features should be available in the PUVA chamber:

Lamps with protective shields

A viewing window for a health care professional to check the person periodically

A door that can be opened by the person easily and with little pressure

A timer that ends the session automatically

An accessible alarm device

Protective Measures After Treatment: The drugs used in PUVA make people more likely to get a natural sunburn for a few
hours after treatment. People should take the following precautions:

Wear UVA absorbing wrap-around sunglasses that are designed to completely block out
stray radiation. People should begin wearing them as soon as they take the drug, and
for at least 12 hours after the treatment. This is important to prevent a PUVA reaction
around the eyes, which may lead to cataracts. There is no need to wear these glasses
after sunset.

For about 8 hours after taking the drug, avoid exposure to daylight, even if the day
is cloudy or exposure is only through windows.

Wear heavy opaque clothing (clothes that do not let light through) outside, including
hats and gloves.

Apply sun block over all exposed areas, including the lips. The sun block should have
a sun protection factor (SPF) of more than 15 and include ingredients that block both
UVB and UVA radiation.

Do not spend a long time in sunlight for at least 2 days after the combined treatment.

UVB Therapy

Ultraviolet B, another part of sunlight, is the main cause of sunburn. It generally
affects the outer skin layers. UVB radiation reduces the abnormally rapid skin cell
growth that occurs with psoriasis.

Types of UVB therapy:

Broadband UVB

Narrowband UVB (NB-UVB)

Laser treatments

Broadband Ultraviolet B (UVB) Radiation

Broad spectrum or broadband UVB is radiation in the wavelength of 290 to 350 nanometers,
and is the standard UVB phototherapy treatment in the United States. It is not as
potent as the treatments that use narrowband UVB or PUVA, and is not useful for chronic
psoriasis.

Broadband UVB may be given with or without medications. When used without medication
(known as selective ultraviolet phototherapy), UVB treatment is generally given as
follows:

Treatment starts in the doctor's office or another medical setting. Once the disease
has stabilized, the person can get a prescription for equipment that can be used at
home. Research finds that home UVB treatment is just as safe and effective as hospital-based
treatment, and people may be more likely to get the treatments they need if they administer
them at home. Even at home, treatment must always be supervised.

In preparation, the person fully undresses, although unaffected areas may be covered
to avoid overexposure.

The initial session may last for just a few seconds, depending on whether the person
has lighter or darker skin. The lightest skin is exposed to the briefest session.
The duration increases with each treatment until the skin clears or the person experiences
itching or irritation. The condition may worsen initially.

UVB therapy usually requires about 20 to 40 treatments (about three per week). Full
results take about 3 weeks.

Use of Medication: UVB was commonly used with coal tar (the Goeckerman regimen) in past decades, and
then with anthralin (the Ingram regimen). Other medications are being studied with
some success, and may prove to be better tolerated.

The Goeckerman regimen requires daily treatments for up to 4 weeks. The coal tar or
anthralin is applied once or twice each day and then washed off before the procedure.
Studies indicate that a low-dose (1%) coal tar preparation is as effective as a high-dose
(6%) preparation. Such regimens are unpleasant, but are still useful for some people
with severe psoriasis, because they can achieve long-term remission (up to 6 to 12
months).

Some evidence suggests that using a simple emollient (Vaseline or mineral oil) that
enhances UVB light penetration can be effective. This addition to the treatment increases
the risk for sunburns, however, and people must be careful to avoid sun exposure.
Researchers are trying combinations of other topical and oral medications. For example,
combining UVB with methotrexate or retinoids such as a tazarotene gel or oral enbris
is producing positive results. Combinations with any of these drugs, however, must
be supervised carefully to avoid serious reactions.

Side Effects of UVB: The treatment can cause itching and redness. UVB radiation from sunlight is known
to increase the risk for skin cancers. There is no strong evidence that UVB treatments
pose any risk for skin cancers except on male genitals. This risk, however, can be
significant (4.5%) at high doses.

Narrowband Ultraviolet B (NB-UVB) Radiation

Narrowband radiation may be safer than other approaches, and some scientists now believe
it should be the first option for people with chronic plaque psoriasis.

NB-UVB is used without medications and is very strong. Whether it has any effect on
the disease process itself is unclear. The light wavelength is between 300 to 320
nanometers, which is the most beneficial part of sunlight.

Exposure times are shorter, but of higher intensity than with broadband UVB. This
therapy is probably less likely than PUVA to cause skin cancers.

Clearance of 75% typically occurs after 10 to 12 treatments. NB-UVB treatments performed
three times a week achieve results that are equal to twice-weekly PUVA treatments.
Weekly NB-UVB treatments are not effective. Studies so far are mixed on whether NB-UVB
remission rates are equal to those of PUVA.

People prefer NB-UVB over other PUVA treatments because they do not have to:

Take medications

Experience unpleasant side effects, such as nausea.

NB-UVB is also safe for pregnant women and children.

Combinations with topical medications, such as tazarotene or psoralens, may help NB-UVB
therapy work more effectively.

Laser Treatments

Laser UVB Treatment: A variation of a device called an excimer laser (Xtrac) delivers a precise UVB wavelength
of 308 nanometers. The laser is more effective than narrowband UVB for localized psoriasis,
because it allows very specific areas of skin to be targeted. (Note: The therapy is
not suitable for the scalp.) Generally, 8 to 10 treatments given twice a week will
clear psoriasis. Remission rates are similar to those of NB-UVB, but the excimer laser
can clear the psoriasis faster and at lower doses. It also spares the healthy skin
around it. Blistering is a common side effect. More comparison studies are needed
to determine risks and benefits compared to NB-UVB, particularly any long-term risk
for skin cancer.

Pulsed-Dye Lasers: Pulsed-dye lasers give off high-intensity yellow light, which destroys the tiny
blood vessels that make up psoriatic plaques. This treatment has been used for years
to remove birthmarks, such as port wine stains and unsightly blood vessels on the
skin. Some studies have reported significant (but not complete) improvement of psoriasis,
and remissions that have lasted up to 13 months. Treatment sessions can take up to
30 minutes and can feel uncomfortable (similar to being repeatedly snapped with a
rubber band). It typically takes up to six sessions to clear the target areas. Bruising
is common, and there is a small risk for scarring.

Hematopoietic Stem Cell Transplantation (HSCT)

Hematopoietic stem cell transplantation is a procedure that injects healthy stem cells
into the bone marrow to replace diseased cells. The healthy cells take over and diseases,
such as cancer and autoimmune problems, may go into remission. In some cases, the
therapy is curative. Reports from a small number of people shows that allogeneic transplants,
where stem cells come from a healthy donor, have resulted in remission of psoriasis
(average follow-up 49 months). Autologous HSCT (where stem cells come from the person)
has had less favorable results. More research is needed.

Commercial Tanning Units

Home tanning devices and tanning salons are not usually recommended, but they may
be helpful for people who do not have access to a medical facility. Many people have
achieved a significant reduction in symptoms after taking acitretin and being exposed
to a UVB commercial tanning unit (specifically, a Wolff tanning bed).

However, UV outputs can vary widely among tanning beds and salons. Some units emit
UVA radiation, which poses a higher risk for skin cancers. Adverse effects of tanning
salons that use UVA or UVB radiation are the same as with any UV phototherapies, including
a risk for skin cancer.

Managing Psoriasis

Although sunburn puts people at risk for skin cancer and can make psoriasis worse,
regular exposure to the sun helps clear up psoriasis in people with mild-to-moderate
conditions. People should cover non-affected areas with clothing or sunscreen and
sunbathe only until the skin starts to tan.

Reducing Stress and Anxiety

Because of the association between negative emotions and psoriatic flare-ups, relaxation
and anti-stress techniques may be helpful. Hypnosis aimed at reducing stress may relieve
symptoms.

Some people have had a traumatic or stressful event coincide with the appearance of
psoriasis. Talking to a psychiatrist about the issue may significantly improve symptoms.

Treating Dry Skin

If skin becomes dry and itchy, the person may try the following:

Soak in a warm bath for about 15 minutes.

Afterward, apply salicylic acid, which removes scaly skin and may help moisturizers
and topical prescription medications penetrate the skin.

Then, apply a thick moisturizer or emollient, such as Vaseline, Cetaphil cream, or
Eucerin cream. Lotions are not good enough moisturizers.

Wear special gloves made of Gore-Tex (DermaPore) at night over a thick moisturizer
cream. These gloves are protective but also allow moisture to escape.

Some scientists say that many common moisturizers may actually increase water loss
in psoriasis, but studies have yet to confirm this. In the meantime, if moisturizers
help relieve the condition, people should use them.

Remedies for Itching and Irritation

Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili
peppers. It is used to relieve arthritic pain and may help psoriatic itching. Capsaicin
should be handled using a glove and applied to affected areas three or four times
daily. The person will usually have a burning sensation when the drug is first applied,
but this sensation lessens with use.

Dietary Factors

Folic Acid: People should be sure they get enough of the B vitamin folate (folic acid). Folate-rich
foods include:

Liver

Asparagus

Fruits

Green leafy vegetables

Dried beans and peas

Orange juice

Yeast

Many types of bread and other commercial grain products now have added folic acid.

Omega-3 Fatty Acids: Omega-3 fatty acids, particularly those found in some fish oils, have anti-inflammatory
properties that may benefit some people with psoriasis and other autoimmune conditions.

Vitamin D: Researchers are investigating how Vitamin D may improve psoriasis and psoriatic
arthritis. People should work closely with their physicians however since the supplements
can raise blood calcium levels.

Alternative Remedies

People with persistent psoriasis may be tempted to try alternative or untested treatments,
including herbs and other nontraditional therapies. Green tea slowed the growth of
skin cells in animal studies, and may one day prove useful in treating psoriasis,
but more research is needed.

Various other herbal supplements have been used for psoriasis, but to date no clinical
studies have been reported on these substances. Do not use any unproven therapy without
first consulting a doctor to be sure such treatment is not harmful, and does not interfere
with any medications you are taking.

Herbs and Supplements

Herbal remedies and dietary supplements are not regulated by the FDA. This means that
manufacturers and distributors do not need FDA approval to sell their products. In
addition, any substance that affects the body's chemistry can, like any drug, produce
side effects that may be harmful. There have been many reported cases of serious and
even deadly side effects from herbal products.

The following are special concerns for people taking natural remedies for psoriasis:

Zinc pyrithione is sometimes used, but its effectiveness is doubtful. A number of
so-called natural psoriasis products (Skin-Cap, Blue Cap, and Miralex) that contain
this compound also contain prescription-strength corticosteroids. Such steroids have
the same side effects as those in standard psoriasis drugs. These products have been
banned in the U.S. and Canada, but similar untested medications are available over
the Internet.

Gotu Kola (Centella asiatica) is sometimes applied in a cream for psoriasis. The oral form of the herb has serious
side effects, however, including increasing the risk for miscarriage in pregnant women.

Outlook

Psoriasis is lifelong and is not curable. Although it is also marked by rapid cell
growth, psoriasis is neither cancerous nor contagious.

In general, studies report the following features of its course:

The condition almost always relapses. In a few cases, large areas of plaque can persist
for years.

Psoriasis nearly always goes into remission, however, often clearing on its own.

Increased levels of estrogen may be responsible for this improvement. Relapse may
occur after a woman gives birth.

Emotional and Social Consequences

The emotional and social consequences of psoriasis should not be underestimated.

Many people suffer severe humiliation and depression if plaques are visible. Some
even withdraw from society and become isolated.

Some people are forced to leave their jobs and go on disability if the condition becomes
incapacitating.

Researchers have reported the following:

Surveys of people with psoriasis report a negative mental and physical impact that
is nearly equivalent to that of other major chronic conditions, including cancer,
high blood pressure, diabetes, heart disease, and depression.

In one study, 75% of people reported that psoriasis hurt their confidence.

Another study reported that 8% of people with psoriasis felt their life was not worth
living.

Substance Abuse

Some people, particularly men, use alcohol and smoking as self-medication to reduce
the emotional consequences of psoriasis. In fact, studies have found that people with
psoriasis have higher mortality rates, mostly from heavy drinking. Smoking has also
been cited as a major risk, particularly for pustular psoriasis. Some experts believe
that drinking and smoking may actually cause biological damage that contributes to
psoriasis.

Physical and Medical Complications of Psoriasis

Folate Deficiency in Severe Psoriasis: Severe psoriasis can cause folate deficiency. Folate is a B vitamin that is important
for blood cell formation and preventing birth defects. It also prevents elevations
of homocysteine, a factor that may play a critical role in heart disease.

Skin Cancers: People with severe psoriasis who receive medications that affect the whole body
may be at higher-than-normal risk for developing cancers, primarily skin cancers and
lymphomas. The risk is not elevated in people with mild psoriasis. There is some indication,
however, that people with psoriasis have a higher risk for non-melanoma skin cancers,
regardless of their treatments.

Obesity, diabetes, and heart risks: Psoriasis has been linked to an increased risk of heart attack and cardiovascular
disease, although the link has been observed more in hospital-based studies rather
than people in the community. People with psoriasis are much more likely to have hardening
of the arteries (atherosclerosis) and other blood vessel diseases than people without
psoriasis. People with psoriasis may be at higher risk for high cholesterol/triglyceride
levels as well. These conditions are also related to inflammation, which may be why
people with psoriasis are more likely to develop diabetes and high blood pressure
than people without the condition. It is not yet known whether there are genetic links
between psoriasis and some of these conditions. The connection may also have to do
with shared risk factors, such as smoking and obesity. People with moderate-to-severe
psoriasis should be screened, and possibly treated, for cardiovascular risks.

Complications of Erythrodermic and Pustular Psoriasis

Zumbusch Psoriasis: A combination of erythrodermic and pustular psoriasis causes a serious condition
called Zumbusch psoriasis:

The condition can develop abruptly.

Symptoms can include fever, chills, weight loss, and muscle weakness.

People may develop excessive fluid build-up, protein loss, and electrolyte imbalances.
In such cases, hospitalization is required. Fluid and chemical balances must be restored
and temperature stabilized as soon as possible.

Zumbusch psoriasis can be life threatening, particularly in the elderly. The condition
is very rare in children and, if it occurs, tends to improve more quickly than in
adults, possibly even without medication.

Christopher Cox, M.D., the Medical Director of and an orthopedic surgeon with Sutter
Health CPMC's Total Joint Replacement Center, talks about how to get ready for traditional
hip joint replacement surgery.

Part Three of this series helps you prepare for your trip to the hospital, what
to expect on the day of your procedure, what are the goals for your going home and
making plans for where you can stay immediately after discharge.

Making the Most of Your Total Joint Replacement - Part Three: Going Home